Bottom Line:
Private hospitals had a better compliance to lactate and blood culture sampling and maintenance of glycemic control.The multivariate analysis showed that age, disease severity at baseline and being treated at a public hospital were independent risk factors for mortality.Being treated in a public hospital was an independent factor for mortality.

Background: Previous studies showed higher sepsis mortality rates in Brazil compared to other developed or developing countries. Moreover, another trial demonstrated an increased mortality rate in public hospitals compared to private hospitals in Brazil. The reasons for these findings may include delayed recognition and inadequate treatment of sepsis in public facilities. We designed this study to evaluate the factors associated with mortality in septic patients admitted to intensive care units in a network of public and private institutions.

Materials and methods: This study is a retrospective analysis of a prospective cohort of sepsis patients in 19 private and public institutions in Brazil. We analyzed data from the original database and collected additional data to assess compliance to the treatment guidelines and to determine the time from the onset of organ dysfunction and the sepsis diagnosis by the healthcare team.

Results: A total of 396 patients were analyzed. Patients in public hospitals were younger, had a greater number of dysfunctional organs at baseline and a lower chance to have sepsis diagnosed within two hours of the onset of organ dysfunction. Private hospitals had a better compliance to lactate and blood culture sampling and maintenance of glycemic control. The multivariate analysis showed that age, disease severity at baseline and being treated at a public hospital were independent risk factors for mortality. A delay in the sepsis diagnosis of longer than two hours was associated with mortality only in the public setting.

Conclusions: We confirmed a lower sepsis mortality rate in the private hospitals of this network. Being treated in a public hospital was an independent factor for mortality. Delayed recognition of sepsis was more frequent in public institutions and this might have been associated with a higher mortality. Improving sepsis recognition and early diagnosis may be important targets in public institutions.

pone-0064790-g002: Comparison of propensity scores for patients from public and private hospitals within each propensity score quintile.The groups are comparable because there is sufficient overlap in the propensity score within each block.

Mentions:
The propensity score was as patients and their scores were equality distributed among the score quintiles within the groups (Figure 2). Our model has an AUC of 0.846 to predict the type of hospital. The logistic regression analysis with hospital mortality as dependent variable and patient location as independent variable, including the propensity score as a continuous variable confirmed the type of institution as a independent factor associated with mortality (OR 1.719 CI95%: 1.040–2.843, p = 0.036), with a good calibration by the Hosmer-Lemeshow test (p = 0.841). We also separately analyzed the factors associated with mortality in each type of hospital (Table 3). In the public hospitals, in the multivariate analysis, the variables associated with mortality were age, APACHE II score, the presence of hematologic dysfunction and daily costs. Compared to the non-survivors, among the survivors, there was a higher proportion of patients in whom the sepsis diagnosis was made either within one or two hours. In the private hospitals, the variables that remained in the logistic regression model were only age, SOFA score at the time of diagnosis, daily costs and glycemic control. As opposite of the findings in public hospitals, the time to the sepsis diagnosis was not different between the survivors and non-survivors in the private setting (Table 3).

pone-0064790-g002: Comparison of propensity scores for patients from public and private hospitals within each propensity score quintile.The groups are comparable because there is sufficient overlap in the propensity score within each block.

Mentions:
The propensity score was as patients and their scores were equality distributed among the score quintiles within the groups (Figure 2). Our model has an AUC of 0.846 to predict the type of hospital. The logistic regression analysis with hospital mortality as dependent variable and patient location as independent variable, including the propensity score as a continuous variable confirmed the type of institution as a independent factor associated with mortality (OR 1.719 CI95%: 1.040–2.843, p = 0.036), with a good calibration by the Hosmer-Lemeshow test (p = 0.841). We also separately analyzed the factors associated with mortality in each type of hospital (Table 3). In the public hospitals, in the multivariate analysis, the variables associated with mortality were age, APACHE II score, the presence of hematologic dysfunction and daily costs. Compared to the non-survivors, among the survivors, there was a higher proportion of patients in whom the sepsis diagnosis was made either within one or two hours. In the private hospitals, the variables that remained in the logistic regression model were only age, SOFA score at the time of diagnosis, daily costs and glycemic control. As opposite of the findings in public hospitals, the time to the sepsis diagnosis was not different between the survivors and non-survivors in the private setting (Table 3).

Bottom Line:
Private hospitals had a better compliance to lactate and blood culture sampling and maintenance of glycemic control.The multivariate analysis showed that age, disease severity at baseline and being treated at a public hospital were independent risk factors for mortality.Being treated in a public hospital was an independent factor for mortality.

Background: Previous studies showed higher sepsis mortality rates in Brazil compared to other developed or developing countries. Moreover, another trial demonstrated an increased mortality rate in public hospitals compared to private hospitals in Brazil. The reasons for these findings may include delayed recognition and inadequate treatment of sepsis in public facilities. We designed this study to evaluate the factors associated with mortality in septic patients admitted to intensive care units in a network of public and private institutions.

Materials and methods: This study is a retrospective analysis of a prospective cohort of sepsis patients in 19 private and public institutions in Brazil. We analyzed data from the original database and collected additional data to assess compliance to the treatment guidelines and to determine the time from the onset of organ dysfunction and the sepsis diagnosis by the healthcare team.

Results: A total of 396 patients were analyzed. Patients in public hospitals were younger, had a greater number of dysfunctional organs at baseline and a lower chance to have sepsis diagnosed within two hours of the onset of organ dysfunction. Private hospitals had a better compliance to lactate and blood culture sampling and maintenance of glycemic control. The multivariate analysis showed that age, disease severity at baseline and being treated at a public hospital were independent risk factors for mortality. A delay in the sepsis diagnosis of longer than two hours was associated with mortality only in the public setting.

Conclusions: We confirmed a lower sepsis mortality rate in the private hospitals of this network. Being treated in a public hospital was an independent factor for mortality. Delayed recognition of sepsis was more frequent in public institutions and this might have been associated with a higher mortality. Improving sepsis recognition and early diagnosis may be important targets in public institutions.